Evidence of Efficacy Limited for Multifactorial Fall Prevention Programs

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Evidence of Efficacy Limited for Multifactorial Fall Prevention Programs

CME/CE

http://www.medscape.com/viewarticle/568321?sssdmh=dm1.331117 & src=nldne

News Author: Laurie Barclay, MD

CME Author: Hien T. Nghiem, MD

Disclosures

Release Date: January 7, 2008; Valid for credit through January 7, 2009

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;

Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;

Nurses - 0.25 nursing contact hours (None of these credits is in the

area of pharmacology)

Learning Objectives

Upon completion of this activity, participants will be able to:

1. Report fall prevention interventions.

2. Evaluate the effectiveness of multifactorial assessment and

intervention programs to prevent falls and injuries among older adults.

Author Information and Disclosures

Laurie Barclay, MD

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial

relationships.

Hien T. Nghiem, MD

Disclosure: Hien T. Nghiem, MD, has disclosed no relevant financial

relationships.

Brande

Disclosure: Brande has disclosed no relevant financial

information.

January 7, 2008 — Evidence is limited that multifactorial fall

prevention programs in primary care, community, or emergency care

settings effectively reduce the number of fall or fall-related injuries

in older adults, according to the results of a systematic review and

meta-analysis reported in the December 18 Online First issue of the BMJ.

" The National Institute for Health and Clinical Excellence (NICE)

clinical practice guideline for the assessment and prevention of falls

in older people recommended that multifactorial risk assessment and

individualised interventions should be undertaken, " write S. Gates, from

the Warwick Clinical Trials Unit, University of Warwick, in Coventry,

United Kingdom, and colleagues. " Such services (falls clinics) have now

been introduced throughout the UK NHS [National Health Service] but in

the absence of any evidence about the optimum configuration, they have

varied in location, skill mix, assessments, and interventions offered.

In view of the recent proliferation of falls prevention services using

multifactorial assessment and targeted intervention, and the substantial

amount of new evidence, we re-examined the evidence for the

effectiveness of this strategy. "

Using 6 electronic databases (Medline, EMBASE, CENTRAL, CINAHL,

PsycINFO, Social Science Citation Index) through March 22, 2007, as well

as reference lists of included studies and previous reviews, the study

authors performed a systematic review and meta-analysis of randomized

and quasi-randomized controlled trials. Eligibility criteria for

included studies were those that assessed interventions to prevent

falls, after evaluation of multiple risk factors for falling and

provision of treatments to address these risk factors.

The reviewers extracted data on the number of people who sustain falls,

fall-related injuries, fall rate, mortality, hospitalization, use of

health services, institutionalization, physical activity, and quality of

life. The studies were also reviewed for methodological quality,

including allocation concealment, blinding, losses and exclusions,

intent-to-treat analysis, and reliability of outcome measurement.

The meta-analysis included 19 studies of variable methodological

quality. In 18 trials, the combined risk ratio (RR) for the number of

people who sustain falls during follow-up was 0.91 (95% confidence

interval [CI], 0.82 - 1.02). For fall-related injuries, based on 8

trials, the RR was 0.90 (95% CI, 0.68 - 1.20). The intervention was not

associated with any differences in hospital admissions, emergency

department visits, mortality, or institutionalization.

Analyses of different subgroups showed no evidence of different effects

based on treatment settings, in populations selected or unselected for

high risk for falls, and in multidisciplinary teams including a

clinician. However, interventions actively providing treatments seemed

to be more effective than those offering only education and referral.

" Evidence that multifactorial fall prevention programmes in primary

care, community, or emergency care settings are effective in reducing

the number of fallers or fall related injuries is limited, " the study

authors write. " Data were insufficient to assess fall and injury rates. "

Limitations of the included studies were moderate to poor overall

quality of the evidence, small sample size, methodological limitations,

lack of data on important outcomes, and statistical heterogeneity.

" Although multifactorial fall risk assessment and intervention seems a

plausible and attractive strategy for preventing falls and fall related

injuries in older people it is not supported by strong evidence, " the

study authors conclude. " Higher intensity interventions that provide

treatments to address risk factors rather than information and referral

may be more effective. The costs of implementation of these

interventions have not been extensively studied but as they are likely

to be expensive the cost effectiveness of this type of intervention is

questionable. "

The National Institute of Health Research Service Delivery and

Organisation Programme funded this study. The study authors have

disclosed no relevant financial relationships.

BMJ. Published online December 18, 2007.

Clinical Context

As a result of the aging population and the growing awareness of

morbidity and mortality associated with falls, prevention of falls and

injuries has been a major focus of research. Demonstrated by reviews of

randomized controlled trials, effective fall prevention interventions

include training in strength and balance, modification of hazards at

home, and withdrawal of psychotropic drugs. In addition, systematic

reviews suggest that the most effective way to reduce falls is

multifactorial risk assessment and individualized interventions against

risk factors. This type of intervention has been recommended for the UK

National Health Service in 2001, despite the lacking evidence.

The aim of this study was to evaluate the effectiveness of

multifactorial assessment and intervention programs to prevent falls and

injuries among older adults recruited to trials in primary care,

community, or emergency care settings.

Study Highlights

* This study consisted of a systematic review of eligible

randomized and quasi-randomized controlled trials, and meta-analysis

that evaluated interventions to prevent falls that were based in

emergency departments, primary care, or the community that assessed

multiple risk factors for falling and provided or arranged for

treatments to address these risk factors.

* 6 electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL,

PsycINFO, and Social Science Citation Index) were used from 2003 through

March 22, 2007.

* Control groups could receive standard care or no fall prevention

intervention.

* Outcomes were number of people who sustained falls, fall-related

injuries, fall rate, death, admission to the hospital, contacts with

health services, move to institutional care, physical activity, and

quality of life.

* Exclusion criteria included studies of interventions targeted at

hospital inpatient or residential care populations and studies that did

not report outcomes of falls.

* Methodological quality assessment included allocation

concealment, blinding, losses and exclusions, intent-to-treat analysis,

and reliability of outcome measurement.

* Results included 19 studies of variable methodological quality,

with a total of 6397 participants and performed in 8 countries.

* The combined RR for the number of people sustaining falls during

follow-up among 18 trials was 0.91 (95% CI, 0.82 - 1.02), and for

fall-related injuries (8 trials), the RR was 0.90 (95% CI, 0.68 - 1.20),

suggesting no clear overall effect.

* No differences were found in admissions to the hospital,

emergency department attendance, death, or move to institutional care.

* No studies reported quantitative data on health-related quality

of life or physical activity.

* Subgroup analyses found no evidence of different effects among

interventions in different locations, populations selected or unselected

for high risk for falls, and multidisciplinary teams including a

clinician, but interventions that actively provide treatments may be

more effective than those that provide only knowledge and referral.

* Limitations of this study included the lack of data on important

outcomes such as fall-related injuries, health-related quality of life,

and physical activity; most trials were small; and many trials had

methodological drawbacks leaving them open to bias, such as insecure

allocation concealment, lack of blinding of outcome assessment, high

losses to follow-up, and poor reporting.

Pearls for Practice

* Effective fall prevention strategies include training in strength

and balance, modification of hazards at home, and withdrawal of

psychotropic drugs.

* Evidence that multifactorial fall prevention programs in primary

care, community, or emergency care settings are effective in reducing

the number of people who sustain falls or fall-related injuries is

limited. In addition, data were insufficient to assess fall and injury

rates.

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